Urinary stone disease (urolithiasis) is one of the most common disorders affecting the urinary tract and represents a significant cause of morbidity worldwide.1 The global prevalence of renal calculi has increased steadily over the past few decades due to changes in dietary habits, sedentary lifestyles, obesity, metabolic disorders, and environmental factors.2 It is estimated that approximately 5–15% of the population will develop urinary stones during their lifetime, with recurrence rates approaching 50% within 5–10 years after the initial episode.3 Patients with renal calculi commonly present

with flank pain, hematuria, urinary tract infection, or renal obstruction, and untreated stones may lead to progressive deterioration of renal function, recurrent infections, and impaired quality of life.4

The management of renal stones depends on stone size, location, composition, anatomical considerations, and patient-related factors.5 Small calculi may pass spontaneously or be treated using medical expulsive therapy or extracorporeal shock wave lithotripsy (ESWL).6 However, large renal stones (>20 mm), staghorn calculi, lower calyceal stones, and complex renal calculi often require more invasive interventions.7 Percutaneous nephrolithotomy (PCNL), first introduced in the 1970s, has become the gold standard surgical treatment for large and complex renal stones because of its high stone-free rates and acceptable safety profile.8 The procedure involves creating a percutaneous tract into the renal collecting system, fragmenting the stone using endoscopic instruments, and removing the stone fragments through the nephroscope.

Traditionally, standard PCNL concludes with placement of a nephrostomy tube to ensure adequate drainage of urine, provide hemostasis by tamponading the nephrostomy tract, and facilitate access for secondary procedures if residual stones remain.9 Although nephrostomy tube placement has several advantages, it is also associated with increased postoperative discomfort, flank pain, prolonged analgesic requirements, delayed mobilization, urine leakage around the tube, and extended hospital stay.10 These drawbacks have encouraged urologists to explore less invasive modifications of the conventional procedure that can improve postoperative recovery while maintaining surgical safety.

Tubeless PCNL was introduced as an alternative approach in which the nephrostomy tube is omitted at the completion of surgery, and only an internal ureteral stent or ureteric catheter is left for temporary urinary drainage.11 The rationale behind this technique is to minimize tissue irritation caused by the nephrostomy tube, thereby reducing postoperative pain, decreasing the need for analgesics, promoting earlier ambulation, and shortening hospitalization. Initially, tubeless PCNL was reserved for carefully selected patients with uncomplicated procedures, minimal intraoperative bleeding, complete stone clearance, and no collecting system perforation.12 Over time, increasing surgical experience and advances in endoscopic technology have expanded its application to a broader range of patients.

Numerous clinical studies have reported favorable outcomes with tubeless PCNL, demonstrating reduced postoperative pain, lower analgesic consumption, faster recovery, and shorter hospital stay compared with standard PCNL. Importantly, these benefits have generally been achieved without increasing the risk of significant complications such as hemorrhage, urinary leakage, infection, or the need for secondary interventions. Nevertheless, concerns remain regarding patient selection, postoperative safety, and the potential for complications in more complex stone cases. Consequently, the choice between tubeless and standard PCNL continues to be influenced by surgeon preference, intraoperative findings, and institutional protocols.

With the growing emphasis on minimally invasive surgery, enhanced recovery protocols, and cost-effective healthcare, identifying surgical techniques that improve patient comfort without compromising clinical outcomes has become increasingly important. Comparative evaluation of tubeless and standard PCNL provides valuable evidence regarding their relative effectiveness in routine clinical practice. Therefore, the present study was conducted to compare tubeless and standard percutaneous nephrolithotomy in terms of postoperative pain, analgesic requirement, length of hospital stay, and perioperative complications. The findings of this study are expected to contribute to the optimization of surgical management strategies for patients with renal calculi and support evidence-based decision-making in endourological practice.

This comparative observational study was conducted in the Department of Urology over a two-year period from December 2023 to December 2025. A total of 386 patients diagnosed with renal calculi and scheduled for percutaneous nephrolithotomy (PCNL) were enrolled after obtaining informed consent and institutional ethical approval. Patients aged 18–70 years with renal stones requiring PCNL were included, while those with bleeding disorders, active urinary tract infection, congenital renal anomalies, pregnancy, or requiring multiple access tracts were excluded. Participants were allocated into two groups according to the surgical technique performed: Tubeless PCNL (without nephrostomy tube placement, n = 193) and Standard PCNL (with nephrostomy tube placement, n = 193). All procedures were performed under general anesthesia by experienced urologists using standard operative techniques. Postoperative pain was assessed using the Visual Analog Scale (VAS) at 6, 12, 24, and 48 hours after surgery. Total postoperative analgesic consumption, duration of hospital stay, operative time, estimated blood loss, and perioperative complications including fever, hematuria, urine leakage, blood transfusion, and sepsis were recorded. Complications were graded according to the Clavien–Dindo classification. Data were analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation and compared using the independent t-test, while categorical variables were analyzed using the Chi-square test or Fisher's exact test. A p-value of <0.05 was considered statistically significant.

A total of 386 patients were included in the study, with 193 patients undergoing Tubeless PCNL and 193 patients undergoing Standard PCNL. Baseline demographic and stone characteristics were comparable between the two groups.

Table 1. Baseline Demographic and Clinical Characteristics

Table 2. Operative Outcomes

Table 3. Postoperative Pain Scores (VAS)

Table 4. Postoperative Analgesic Requirement

Table 5. Hospital Stay and Recovery

Table 6. Postoperative Complications

Table 7. Clavien–Dindo Classification of Complications

Patients who underwent Tubeless PCNL experienced significantly lower postoperative pain scores, reduced analgesic requirements, earlier ambulation, and a shorter hospital stay than those treated with Standard PCNL (p < 0.001). Operative time, blood loss, and stone-free rates were comparable between the two groups. Although minor complications such as fever, hematuria, and urine leakage were less frequent in the tubeless group, the incidence of major complications (Clavien–Dindo Grade III or higher), blood transfusion, and sepsis did not differ significantly between the groups, demonstrating that tubeless PCNL provides improved postoperative recovery without compromising safety.

Percutaneous nephrolithotomy (PCNL) remains the gold standard treatment for large and complex renal calculi because of its high stone clearance rate and favorable clinical outcomes.13 The conventional technique involves placement of a nephrostomy tube at the conclusion of surgery to provide urinary drainage, achieve hemostasis, and facilitate access for secondary procedures if required.14 However, the nephrostomy tube is often associated with increased postoperative pain, prolonged analgesic use, delayed mobilization, and longer hospitalization.15 Tubeless PCNL was introduced to overcome these limitations while maintaining the safety and efficacy of the standard procedure. The present study compared tubeless and standard PCNL in terms of postoperative recovery and perioperative complications.

The findings of this study demonstrated that patients undergoing tubeless PCNL experienced significantly lower postoperative pain scores at 6, 12, 24, and 48 hours after surgery compared with those treated by standard PCNL. The absence of a nephrostomy tube likely reduces irritation of the renal capsule and surrounding tissues, resulting in improved patient comfort. Similar findings have been reported in several randomized controlled trials and meta-analyses, which consistently show lower Visual Analog Scale (VAS) scores among patients undergoing tubeless PCNL.

Corresponding to the reduction in pain, postoperative analgesic consumption was significantly lower in the tubeless PCNL group. Reduced opioid and non-opioid analgesic requirements not only improve patient satisfaction but also decrease the risk of medication-related adverse effects such as nausea, vomiting, respiratory depression, and delayed recovery. These findings are consistent with previous studies that have identified nephrostomy tube placement as one of the principal contributors to postoperative discomfort following PCNL.

Hospital stay was significantly shorter among patients treated with tubeless PCNL. Earlier ambulation, reduced pain, and faster postoperative recovery allowed earlier discharge compared with the standard PCNL group. Shorter hospitalization has important clinical and economic implications, including lower healthcare costs, improved bed availability, and faster return of patients to their normal daily activities. Enhanced recovery protocols increasingly support minimally invasive techniques such as tubeless PCNL to optimize postoperative outcomes.

The present study also demonstrated comparable operative time, estimated blood loss, and stone-free rates between tubeless and standard PCNL. These findings indicate that omission of the nephrostomy tube does not compromise the effectiveness of stone removal or procedural success when patients are appropriately selected. High stone-free rates in both groups confirm that tubeless PCNL maintains the primary objective of achieving complete stone clearance.

Regarding postoperative complications, the overall incidence was similar between the two groups. Minor complications, including transient fever, mild hematuria, and urine leakage, occurred slightly more frequently in the standard PCNL group, whereas major complications such as blood transfusion, sepsis, and Clavien–Dindo Grade III or higher events did not differ significantly. These results support previous evidence that tubeless PCNL does not increase perioperative morbidity when performed in patients with complete stone clearance, minimal bleeding, and no significant collecting system injury.

The strengths of the present study include a relatively large sample size, standardized assessment of postoperative outcomes, and comprehensive evaluation of pain, analgesic requirements, hospital stay, and complications. Nevertheless, several limitations should be acknowledged. The observational study design may introduce selection bias, and patients were selected for tubeless PCNL based on favorable intraoperative findings. Furthermore, long-term outcomes such as stone recurrence, renal function, quality of life, and cost-effectiveness were not evaluated. Future multicenter randomized controlled trials with extended follow-up are warranted to further validate the long-term safety and effectiveness of tubeless PCNL across diverse patient populations.

Overall, the findings of this study reinforce the growing body of evidence that tubeless PCNL is a safe, effective, and less invasive alternative to standard PCNL. In carefully selected patients, it provides superior postoperative recovery through reduced pain, lower analgesic requirements, earlier mobilization, and shorter hospital stay while maintaining comparable stone-free rates and complication profiles. These advantages support the broader adoption of tubeless PCNL as part of modern minimally invasive management strategies for renal stone disease,

Tubeless percutaneous nephrolithotomy is a safe and effective alternative to standard PCNL in appropriately selected patients. It provides significantly lower postoperative pain, reduced analgesic requirements, earlier recovery, and shorter hospital stay while maintaining comparable stone-free rates and complication profiles. These findings support the use of tubeless PCNL as a minimally invasive approach that enhances postoperative recovery without compromising patient safety or surgical success.

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